An Open Reply to a Pharmacist Regarding Prescription Drug Monitoring

Last month I wrote an op-ed and a follow-up blog post critical of a proposal to expand Colorado’s prescription drug monitoring program. I pointed out (among other things) that the program was promoted and financed largely by federal law enforcement; that law enforcement agents can access the information in the database (by warrant) for purposes of pursuing criminal investigations; that the program does little to curb drug abuse, in part because drug abusers easily can switch to different drugs, and in part because some drug abusers steal their drugs (or, I’ll add here, buy them on the black market); and that the proposal seeks to force doctors (and other prescribers) to register with the database.

My main point was that it is not the government’s proper role to save drug addicts from their own dangerous behavior—particularly given the government’s actions in this area inevitably make it harder for some people to obtain the drugs they desperately need to manage their excruciating pain.

On March 31, someone who identified himself only as “John” replied to my web page:

Ari, hello. My name is John and I am a retail pharmacist. I rely heavily on our prescription monitoring program here in Nevada. As pharmacists, we use it to make sure people are not filling multiple controlled substance prescriptions at different pharmacies, using multiple doctors for controlled substances, and that they are not misusing or abusing controlled substances. This tool has prevented abuse and diversion in our state and is a very useful tool. Also, to stress an important point, a good pharmacist understands true pain (cancer) and always strives to take compassionate care of the patient.

Following is my open reply:

Dear John,

As a pharmacist, you are undoubtedly a smart fellow; you must realize, therefore, that you have not actually responded to any of the observations or arguments I make in my op-ed and related post.

I have no doubt that the monitoring programs set up by the governments of various states prevent some drug addicts from obtaining certain drugs from certain sources. (Whether it substantially prevents drug addicts from abusing drugs, on the other hand, is extremely doubtful.) My primary philosophical objection is that it is not the government’s proper role to address or prevent the problem of drug abuse; rather, it is to protect people’s rights, including the rights of consenting adults to contract freely. Although a full defense of that position lies outside the scope of this short letter, I will note here that there are other—and much better—ways to help drug addicts with their problems.

I will also note here that my criticisms of government-run drug prescription drug monitoring programs (run largely at the behest of federal law enforcement agents) do not constitute reasons to prohibit doctors and pharmacists from independently sharing certain information about potentially dangerous situations. And of course nothing in my position implies that reckless doctors should be free from civil and even (if circumstances warrant) criminal liability.

As a pharmacist, your ability to “take compassionate care of the patient” is inherently limited. After all, you are not legally authorized to diagnose any disease or to write drug prescriptions. Thus, there is no case in which you can actually expand the delivery of pain medications to the patients who desperately need them. Your actions can have one and only one effect in this regard: to block or delay such delivery.

Of course, your actions might also have the effect of subjecting the doctors and other medical professionals, who are legally authorized to write drug prescriptions, to the actions of federal and state law enforcement agents. Those agents, in turn, have the power in some cases to arrest doctors and to help other government agents prosecute doctors or strip them of their ability to practice medicine.

As a pharmacist, John, you are not in any danger of having your power stripped to write drug prescriptions (as you have no such power) or of being prosecuted for writing drug prescriptions (as you do not write any). You are, however, quite capable of assisting federal and state drug enforcement agents create a climate of fear and intimidation among those who do write drug prescriptions, such that, on balance, those who prescribe drugs tend to err on the side of legal precaution and not help people coping with excruciating pain obtain the drugs they desperately need. Such a result is possible—and I think likely—even assuming (as I’m sure is the case) that most uses of the monitoring program do not involve law enforcement. And the more the program is expanded, the more substantial will be its effects in this regard.

In using the monitoring program, you act primarily on guesswork and speculation. Consider the activities that you regard as inherently suspicious: people “filling multiple controlled substance prescriptions at different pharmacies” and “using multiple doctors for controlled substances.”

Again, I do not doubt that such behavior describes some drug addicts. But I also do not doubt that such behavior also describes some people coping with excruciating pain due to cancer or other serious diseases.

Consider that cancer patients and others coping with serious illnesses typically see multiple doctors in multiple locations to manage their diseases. They also typically use different types of pain medications concurrently to cope with their diseases. Moreover, cancer patients often end up leaving their jobs, moving to a different location, and switching their insurance companies—developments that can result in them seeing more doctors in more locations. Add to this the fact that people suffering from a variety of diseases often require supplemental surgeries—surgeries that initially cause enormous pain and that involve yet more medical facilities. For all these reasons, people coping with such diseases very often get multiple drug prescriptions, written by multiple doctors, filled at multiple pharmacies—the very behaviors that you claim to “make sure” to treat as suspicious.

As a pharmacist, John, you typically lack access to the pertinent information about such patients, and when you lack such information you cannot possibly “take compassionate care” of them. With respect to such patients, your actions can have one and only one result: to make it harder for them to obtain the pain medications they so desperately need.

I will thus repeat here what I wrote at the outset: “the answer is not for the government to monitor and harass people who suffer from devastating pain—and make it harder for them to manage their pain—in a misguided attempt to save drug abusers from themselves.”